Table 6 Description of the final set of indicators
Categories | Indicators | Description | Measurement | Data source |
|---|---|---|---|---|
1. Access | 1.1 Personal doctor | GP is the personal doctor providing continuous care for T2DM patient | The percentage of T2DM patients who recognize that they are being managed by a personal doctor | Patient survey |
1.2 GP team | Patient is being managed by a functioning GP team (a GP, nurse, and preventive care physician) | The percentage of T2DM patients who recognize that they are being managed by a functioning GP team | Patient survey | |
1.3 Waiting time | Waiting time for consultation is reasonable for the patient | The percentage of T2DM patients who recognize that the waiting time for consultation is reasonable | Patient survey | |
1.4 Health advice | Seeking health advice from the GP team is convenient for the patient | The percentage of T2DM patients who recognize that it is convenient to seek health advice from the GP team | Patient survey | |
1.5 Referral access | Patient has ensured referral access to necessary specialist care | The percentage of T2DM patients who recognize that referral access to necessary specialist care is ensured | Patient survey | |
2. Monitoring | 2.1 Regular follow up | At least 4 times of follow up by the GP team in the audit year | The percentage of T2DM patients who are followed up for at least 4 times by the GP team in the audit year | EHR |
2.2 Plasma blood glucose monitoring | At least 4 measurements of plasma blood glucose test (fasting or post-prandial) by the GP team in the audit year | The percentage of T2DM patients who have at least 4 measurements of plasma blood glucose test (fasting or post-prandial) by the GP team in the audit year | EHR | |
2.3 HbA1c monitoring | At least 2 measurements of HbA1c test in the audit year | The percentage of T2DM patients who have at least 2 measurements of HbA1c test in the audit year | EHR | |
2.4 BP monitoring | At least 4 measurements of BP by the GP team in the audit year | The percentage of T2DM patients who have at least 4 measurements of BP by the GP team in the audit year | EHR | |
2.5 Lipid monitoring | At least 1 measurement of lipid test in the audit year | The percentage of T2DM patients who have at least 1 measurement of lipid test in the audit year Tests: TC, TG, LDL-C, HDL-C | EHR | |
2.6 BMI monitoring | At least 1 measurement of BMI in the audit year | The percentage of T2DM patients who have at least 1 measurement of BMI in the audit year | EHR | |
2.7 Waist circumference monitoring | At least 1 measurement of waist circumference in the audit year | The percentage of T2DM patients who have at least 1 measurement of waist circumference in the audit year | EHR | |
2.8 ECG monitoring | At least 1 measurement of ECG in the audit year | The percentage of T2DM patients who have at least 1 measurement of ECG in the audit year | EHR | |
2.9 Nephropathy monitoring | At least 1 nephropathy examination in the audit year | The percentage of T2DM patients who have at least 1 nephropathy examination in the audit year Tests: creatinine, blood urea nitrogen, urine protein | EHR | |
2.10 Retinopathy monitoring | At least 1 retinopathy examination in the audit year | The percentage of T2DM patients who have at least 1 retinopathy examination in the audit year Tests: vision, funduscope or fundus photography | EHR | |
2.11 Peripheral neuropathy monitoring | At least 1 peripheral neuropathy examination in the audit year | The percentage of T2DM patients who have at least 1 peripheral neuropathy examination in the audit year Tests: temperature, pinprick sensation and vibration sensation, 10-g monofilament testing | EHR | |
2.12 Foot monitoring | At least 1 diabetic foot examination in the audit year | The percentage of T2DM patients who have at least 1 diabetic foot examination in the audit year Tests: Skin inspection, pulse palpation | EHR | |
3. Health counseling | 3.1 Diet counseling | Diet counseling is provided for the patient in the audit year | The percentage of T2DM patients who are provided with diet counseling in the audit year | Patient survey |
3.2 Exercise counseling | Exercise counseling is provided for the patient in the audit year | The percentage of T2DM patients who are provided with exercise counseling in the audit year | Patient survey | |
3.3 Psychological assessment or counseling | Psychological assessment is provided for the patient or referral to professional counseling when necessary in the audit year | The percentage of T2DM patients who are provided with psychological assessment or referral to professional counseling when necessary in the audit year | Patient survey | |
3.4 Smoking assessment or counseling | Smoking assessment is provided for the patient or referral to professional counseling when necessary in the audit year | The percentage of T2DM patients who are provided with smoking assessment or referral to professional counseling when necessary in the audit year | Patient survey | |
3.5 Hypoglycemia awareness counseling | Hypoglycemia awareness counseling is provided for the patient in the audit year | The percentage of T2DM patients who are provided with hypoglycemia awareness counseling in the audit year | Patient survey | |
3.6 Medication safety counseling | Medication safety counseling is provided for the patient in the audit year | The percentage of T2DM patients who are provided with medication safety counseling in the audit year | Patient survey | |
3.7 Emergency help counseling | Emergency help counseling is provided for the patient to improve the patient’s knowledge on seeking emergency help in the audit year | The percentage of T2DM patients who are provided with emergency help counseling in the audit year | Patient survey | |
4. Records | 4.1 Follow up records | Follow up records are kept in the audit year | The percentage of T2DM patients whose follow up records are kept in the audit year | EHR |
4.2 Annual management summary report | Annual management summary report, including summary of management status and comprehensive physical examination report are kept in the audit year | The percentage of T2DM patients whose annual management summary reports are kept in the audit year | EHR | |
5. Health status | 5.1 Blood glucose target | The patient’s latest fasting blood glucose is between 4.4–7.0 mmol/L; and post prandial blood glucose < 10.0 mmol/L in the audit year | The percentage of T2DM patients whose latest blood glucose is under control in the audit year based on the following criteria: Fasting blood glucose is between 4.4–7.0 mmol/L; Post prandial blood glucose < 10.0 mmol/L. | EHR |
5.2 HbA1c target | The patient’s latest HbA1c < 7%; or HbA1c < 8% (for patient with severe hypoglycemia or age ≥ 80 or micro or macro vascular complications) in the audit year | The percentage of T2DM patients whose latest HbA1c is under control in the audit year based on the following criteria: HbA1c < 7%; or HbA1c < 8% (for patients with severe hypoglycemia or age ≥ 80 or micro or macro vascular complications). | EHR | |
5.3 BP target | The patient’s latest BP < 130/80 mmHg; or BP < 140/90 mmHg for old patient or patient with CHD in the audit year | The percentage of T2DM patients whose latest BP is under control in the audit year based on the following criteria: BP < 130/80 mmHg; or < 140/90 for old patient or patient with CHD | EHR | |
5.4 Blood lipid target | The patient’s latest LDL-C < 1.8 mmol/L (for patient with ASCVD); or LDL-C < 2.6 mmol/L (for patient without ASCVD) in the audit year | The percentage of T2DM patients whose latest LDL-C is under control in the audit year based on the following criteria: LDL-C < 1.8 mmol/L (with ASCVD); or LDL-C < 2.6 mmol/L (without ASCVD). | EHR | |
5.5 BMI target | The patient’s latest BMI < 24 kg/m2 in the audit year | The percentage of T2DM patients whose latest BMI < 24 kg/m2 in the audit year | EHR | |
5.6 Hypoglycemia episodes | The patient’s episodes of hypoglycemia (including symptomatic hypoglycemia and test results) in the most recent month during the audit year | The percentage of T2DM patients who experienced episodes of hypoglycemia (including symptomatic hypoglycemia and test results) in the most recent month during the audit year | Patient survey | |
5.7 T2DM related admissions to hospital | The patient’s T2DM related admissions to hospital in the audit year | The percentage of T2DM patients who experienced T2DM related admissions to hospital in the audit year | Patient survey | |
6. Patient satisfaction | 6.1 Satisfaction with treatment | The patient’s perceived satisfaction with treatment | Score of DTSQ from T2DM patients in the audit year | Patient survey |
6.2 Satisfaction with communication | The patient’s perceived satisfaction with communication | Score of communication satisfaction from T2DM patients in the audit year | Patient survey | |
7. Self-management | 7.1 Knowledge of self-management | The patient’s knowledge of self-management | Score of MDKT from T2DM patients in the audit year | Patient survey |
7.2 Adherence to medication | The patient’s adherence to medication | Score of Morisky 8 Item Scale from T2DM patients in the audit year | Patient survey | |
7.3 Adherence to healthy behavior | The patient’s adherence to healthy behavior | Score of SDSCA from T2DM patients in the audit year | Patient survey |